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Squawk / 6 hours agoCrude oil and gasoline paring back earlier gains after the weekly inventories showed a bigger rise than expected. The rise of 3 million barrels of crude was caused by a sharp reduction in refinery activity which more than off-set a reduction in imports. Both Cushing inventories and overall production rose thereby adding some additional selling pressure.3hHi Ole, what do all these datas say us? keeping short in WTI? or what else. thanks
Calendar event / 6 hours ago
US EIA Weekly Petroleum Status ReportpreviousforecastactualHigh Crude Oil Stocks, Net Chg (Bbl)+3.955M+2.5M+3.073MHigh Gasoline Stocks, Net Chg (Bbl)+3.254M-0.1M+1.91MHigh Distillate Stocks, Net Chg (Bbl)-0.267M-0.6M-2.458MMed Crude Oil Stocks (Bbl)457.924M460.997MMed Gasoline Stocks (Bbl)222.01M223.92MMed Distillate Stocks (Bbl)151.608M149.15MMed Refinery Usage89.8%89%87.5%Med Total Prod Supplied (Bbl/day)19.592M18.875MMed Total Prod Supplied, Net Chg (Bbl/day)-0.549M-0.717M
Trade view / 7 hours agoShort term
UPDATE: Gold has trended higher after NFPGold's pattern that we identified two days ago has led to a relatively smooth trending move higher, so consider taking some profits in the resistance zone and moving stops to breakeven.Read the Trade View
Squawk / 8 hours agoBefore us open and for intraday strategy sell XAU and XAG at cmp $1153-55 range and $16-16.080 range
keep sl $1162+$16.25
and tgt1 $1140+$15.65.mm3hотличная идея!!!
Article / 8 hours ago
Everyone waits for Fed to do the heavy liftingSterling gained on the back of good UK industrial production data and M&A news around brewer SABMiller, which was seen boosting demand for cash, but the Bank of Japan's meeting left us none the wiser, and markets seem resigned to wait again for the Fed to do the heavy work.Read the article7hinformative and witty - helmet on !!!
Article / 9 hours ago
Silver is shining, but what about gold?The relief rally that followed lastweek's soft nonfarm payrolls print continues to support global markets, particularly emerging markets where buyers have returned to support currencies, stocks and bonds.Read the article
Saxo TV / 9 hours ago
The crude facts: Breakouts, strippers and oilOle HansenAfter weeks of being stuck in a range, crude oil has broken out. Saxo's Ole Hansen on what's behind the move upwards and whether it's here to stay.
Article / 10 hours ago
Daily Shot: Dollar knocks US off balanceDollar strength is seeping through to US trade figures leaving a nasty trade deficit that beat expectations and could impact the economy down the line.Read the article
Article / 11 hours ago
What's next for crude oil after the breakout?Signs of slowing non-Opec production and forecasts of accelerating demand into 2016 have sparked a rally in crude oil which surged above its trading range on Tuesday. Stabilising commodity prices combined with the pushback of US rate hike expectations have broken the vicious circle which led to plunging stocks, bonds and currencies across many emerging markets.Read the article
Editor's Picks / 11 hours ago
Coal fundamentals grim: GlencoreBloombergWhile many investors are concerned about the ultimate fate of Anglo-Swiss commodities trader Glencore, the company is more concerned with the commodities themselves. With world coal prices having fallen to an eight-year low, Glencore head of coal Peter Freyburg says that macro conditions appear unlikely to boost the fuel anytime soon. ""Times are very tough and coal continues to face challenges", says Freyburg, adding that "growth rates in much of the developing world – most obviously in China – have slowed considerably". Although this situation does not show any signs of turning around, however, Freyburg does note that Glencore's "long-term thermal supply and demand outlook has never relied on ongoing Chinese import growth". Glencore shares are currently trading at 122.80 pence on the London exchange.Read article on Bloomberg


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3 posts tagged with exercise by rongorongo.
Displaying 1 through 3 of 3.
Just don't do it!
"At Stanford University two sales representatives from Nike were watching the athletics team practise. Part of their job was to gather feedback from the company's sponsored runners about which shoes they preferred. Unfortunately, it was proving difficult that day as the runners all seemed to prefer... nothing" - from Christopher McDougall's forthcoming book "Born to Run" which looks at the story the growth of the $20 billion running shoe industry. Starting form Bill Bowerman's Cortez in 1972 onwards runners have seen a steady flow of innovations to improve performance and reduce injury rates. Only it would appear they may not work. By way of contrast the book includes coverage of the Mexican Tarahumara tribe who run ultramarathons with shoes made from car tyres on their feet.
5BX: When wishing is not good enough
Bill Orban developed the "Five Basic Exercises" or 5BX program for the Royal Canadian Air force in the late 50s. Apart from the primary aim of getting people into shape it was designed to be simple to perform, to work on all the body, to require nothing in terms of special equipment or large spaces, to accommodate enough progression to cater for reformed couch potato and budding athlete alike and to fit into a time slot of 11 minutes including warm up. [Women, for whatever reason, were prescribed 10 exercises in 12 minutes with XBX]. The book of the exercises was translated into 13 languages and sold 23 million copies around the world before falling into obscurity in the 80s. [more inside]
Exercise and the Placebo Effect
Cleaning hotel rooms is a strenuous business. However, when Alia Crum and Ellen Langer talked to 84 maids, most were under the impression that they did not get enough exercise. Furthermore, when they were measured for tests such as BMI and blood pressure, their results were typical of couch potatoes. The researchers let half the group in on the knowledge that they were getting more than enough of a daily workout and kept the rest in the dark. After a month results showed the former group were healthier on every single one of the objective health measurements tested - despite claiming to have been doing no more exercise or to have changed their diet. The study raises the possibility that mindset alone can influence our metabolism. Christopher Shea in the New York Times and Ben Goldacre in The Guardian have articles discussing the original paper.
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Dupuytren's disease of the hand is a common condition affecting the palmar fascia, resulting in progressive flexion deformities of the digits and hence limitation of hand function. The optimal treatment remains unclear as outcomes studies have used a variety of measures for assessment.
A literature search was performed for all publications describing surgical treatment, percutaneous needle aponeurotomy or collagenase injection for primary or recurrent Dupuytren's disease where outcomes had been monitored using functional measures.
Ninety-one studies met the inclusion criteria. Twenty-two studies reported outcomes using patient reported outcome measures (PROMs) ranging from validated questionnaires to self-reported measures for return to work and self-rated disability. The Disability of Arm, Shoulder and Hand (DASH) score was the most utilised patient-reported function measure (n=11). Patient satisfaction was reported by eighteen studies but no single method was used consistently. Range of movement was the most frequent physical measure and was reported in all 91 studies. However, the methods of measurement and reporting varied, with seventeen different techniques being used. Other physical measures included grip and pinch strength and sensibility, again with variations in measurement protocols. The mean follow-up time ranged from 2 weeks to 17 years.
There is little consistency in the reporting of outcomes for interventions in patients with Dupuytren's disease, making it impossible to compare the efficacy of different treatment modalities. Although there are limitations to the existing generic patient reported outcomes measures, a combination of these together with a disease-specific questionnaire, and physical measures of active and passive individual joint Range of movement (ROM), grip and sensibility using standardised protocols should be used for future outcomes studies. As Dupuytren's disease tends to recur following treatment as well as extend to involve other areas of the hand, follow-up times should be standardised and designed to capture both short and long term outcomes.
Keywords:Dupuytren's disease; Hand function; Outcome measures; Systematic review
Dupuytren's disease (DD) is a common fibroproliferative disorder of the hand affecting 4-6% of the population in northern Europe [1]. It is characterized by the progressive thickening and shortening of the palmar fascia, resulting in the formation of cords, flexion deformities of the digits, and hence loss of range of motion, particularly functional extension [2]. DD often restricts a patient's ability to undertake daily activities of living, depending on the location, extent and severity of disease. The deterioration in hand function is the main motivator for patients seeking treatment [3].
DD is progressive, advancing at varying rates, and may occur bilaterally. It can also recur in the same digit following treatment or appear at another site in the hand (disease extension). Furthermore, the effects of recurrence are not uniform and some patients may opt to have further intervention. Therefore, the development of a uniform set of measures to accurately assess functional impairment has proved challenging.
Most patients with early disease, i.e. before the development of digital contractures, are left untreated, although radiation [4] and steroid injections [5] have been used. Currently, the mainstay of treatment for patients with established flexion deformities is surgery in combination with hand therapy. The aim of surgical procedures for DD is to preserve and, if possible, improve hand function. Surgery comprises either the division (fasciotomy) or removal (fasciectomy or dermofasciectomy) of the diseased tissue. Needle fasciotomy divides the cord in a minimally invasive manner. However, recurrence is common, with one study [6] reporting a rate of 84.9% at 5 years following needle fasciotomy compared with 20.9% following limited surgical fasciectomy. Discontinuity of the cords may also be achieved enzymatically, with 77% of metacarpophalangeal joints and 40% of proximal interphalangeal joints being corrected to within 5 degrees of full extension [7]. However, like needle fasciotomy, recurrence rates are high, affecting 56% of PIP joints and 27% of MCP joints at 3 years [8].
The need for a systematic review on outcomes used in Dupuytren's disease
The optimal treatment in DD remains controversial, in large part due to the lack of evidence based on good quality clinical outcomes studies. Not only is there a paucity of research reporting functional outcomes data for DD but also a lack of consensus on the parameters that should be used. Traditionally, the evaluation of treatment success for DD has largely been determined by clinical examination and physical measures, although improvement in physical measures does not necessarily reflect function [9]. Functional outcome measures specifically assess the consequences of impairment in daily activities. A recent systematic review of efficacy and safety of DD surgery in European patients noted that the commonest outcome measure was improvement in mean joint contracture [10]. However, hand function outcomes were not included in this review. The scarcity of studies reporting functional outcomes following treatment for DD has previously been highlighted [11] and noted in a review of surgical treatments for primary DD [12]. More recent studies have monitored functional outcomes using patient reported outcome measures (PROMs), which have been recognised as an important measure of the effectiveness of care from the patient's perspective [13].
The aim of this review is to identify and determine the relevance and efficacy of outcomes measures used to assess change in hand function following treatment DD by surgery, needle fasciotomy or collagenase injection. This will provide an evidence base to inform the selection of appropriate measures for future research on the management of patients with DD.
Search strategy
The search strategy and search terms were based on a Participants, Intervention, Comparison, Outcomes and Study design (PICOS) [14] (Additional file 1: Table 1). We included studies published over the last 20 years in the English language of adults who had surgery, needle fasciotomy or collagenase injection for primary or recurrent DD where outcomes were monitored using standardised PROMs, functional tests or physical measures as opposed to recording unsubstantiated improvement. Functional outcomes measures reported in randomised and non-randomised controlled clinical trials, prospective and retrospective case series were included. Non-invasive interventions including radiotherapy, steroid injection alone, splinting and skeletal traction were also excluded, as were case studies, conference abstracts and letters. There was no restriction regarding the time that patients were monitored post-intervention.
Additional file 1: Table 1. Search strategy and Search terms using PICOS analysis.
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This file can be viewed with: Microsoft Word Viewer
Search methods for identification of studies
A literature search was performed in July 2012 using subject heading and free-text terms. Three databases, Ovid Medline, Embase and CINAHL (via EBSCOHost) were searched from 1992 to July 2012. PubMed was also searched from September 2010 - July 2012 to capture electronic publication ahead of print studies not included in Ovid Medline. Searches were limited to studies in English. Search results were imported into an EndNote library and 616 publications were identified for title/abstract review after removal of duplicates.
Two authors (CB, ALP) individually screened the studies using the study eligibility tool to identify studies for inclusion with information gained from the electronic databases (minimum title). Where necessary, consensus was achieved by reviewing the full text. Five hundred and twenty five studies were excluded, resulting in 90 articles meeting the inclusion criteria. Following detailed assessment of the included articles, one further publication was identified from their reference lists. The study selection process is summarised in Additional file 2: Figure 1.
Additional file 2: Figure 1. Study selection process flow chart.
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Data collection and analysis
Data on intervention, population and outcomes were collected and tabulated on a Microsoft Excel (Microsoft, Seattle) spreadsheet. Amalgamation of data for statistical analysis was not possible due to the heterogeneity of the studies. Therefore, description of the data is presented to illustrate the variety of functional outcome measures used and the quality of the data. Where available, numerical data are presented as means with range and standard deviation.
Clinical study design
Of the 91 included studies, 66 pertained to surgery, 16 to needle fasciotomy and 9 to collagenase injection. All 9 publications reporting the outcomes of collagenase injection were randomised controlled trials or prospective studies. Many studies reporting surgery (n=29, 43.3%) were retrospective reviews. Eighteen publications reporting outcomes for surgery and 4 needle fasciotomy studies were prospective. In 17 studies (18.7%) it was not possible to establish whether they were prospective or retrospective in design and were categorised as 'unclear'. The functional outcomes used for each of the three interventions is summarised in Additional file 3: Table 2.
Patient reported outcome measures (PROMs)
Measures of function
Twenty-two studies included patient reported data using function PROMs with 13 using validated region-specific questionnaires: the Disability of Arm, Shoulder and Hand (DASH) (n=11), Quick-DASH (n=1) and the Patient Evaluation Measure (PEM) (n=1). Two used the Michigan Hand Outcomes Questionnaire (MHQ) in addition to the DASH. A recently developed disease-specific questionnaire, Unité Rhumatologique de Affections de la Main scale (URAM), was utilised by one study [15] and 8 used other self-report measures such as return to work or self-rated disability. A further 5 reported the use of function PROMs but did not present the results [16]–[20]. The use of PROMs is summarised in Figure 1.
Figure 1. Use of function patient reported outcome measures according to intervention surgery, needle fasciotomy and collagenase injection.
The DASH questionnaire [21] was the most frequently used function PROM (11 studies) but only 6 studies presented calculated pre-and post-treatment data [22]–[27] (Table 1).
Table 1. Number of study subjects and timing of post treatment assessment in studies using DASH and reporting pre- and post-operative data)
The DASH score is calculated using the formula ((sum of n responses) -1)/nx25), where n represents the number of completed items, resulting in an aggregate calculated score ranging from 0 to 100, with a higher score indicating a greater level of disability [21]. Mean pre-treatment values ranged from 12.1 (SD 2.9) [23] to 24 (SD 20) [25] and post-treatment from 3.44 (range 0 to 52.5) [28] to 8 (SD 8) [25]. It should be noted that a further two studies presented uncalculated or 'raw' DASH scores evidenced by reporting a score in excess of 100 [29] or interpreting a score of 30 as 'no self-perceived disability' [30] and were excluded as presentation of the data in this way precluded comparison with other studies.
Two studies additionally used the Michigan Hand Questionnaire (MHQ) [23,25]. The MHQ [31] is scored using an algorithm described in the MHQ codebook [32]. Scores can range from 0–100 for each hand, with higher values representing better function, except for pain, where a higher score indicates more pain. Both studies reported significantly improved global MHQ scores compared to pre-operative scores.
One study utilised the Patient Evaluation Measure (PEM) [33]. The PEM is a validated PROM [34] comprising 3 sections combining hand function and satisfaction with outcome and treatment by asking patients to compare their current versus pre-treatment hand function. The questionnaire is not administered before treatment. The score is calculated by summing the value of the 14 questions in parts 2 and 3 of the PEM and expressed as a percentage of the maximum possible score, with 0% representing a 'normal' hand. The study assessed hand function and disability in a retrospective postal audit at a mean follow-up of 27 months (SD 8, range not given) and found a correlation with patient assessed deformity. PEM scores ranged from 9 (SD14, range not given) for patients with no deformity to 57 (SD 25, range not given) for severe deformities at both the MCP and PIP joints.
Mean final follow-up times for function PROMs ranged from 3 months [22,35] to 4.5 years [36]. Final follow up times for studies recording pre- and post-operative DASH scores varied between 5 weeks and 48 months.
Patient satisfaction
Eighteen studies used patient satisfaction as an outcome, with no single method used consistently. These included a visual analogue scale of satisfaction [27,37]–[39], satisfaction with treatment [40,41], as well as various descriptive responses such as 'very pleased, pleased or disappointed [42], or 'rating of overall clinical success' [39]. Follow-up times ranged from 1 month [43] to median of 4 years (range 1 – 15) [41].
Tests of function
Two studies [44,45] utilised the Sollerman hand function test. The Sollerman test comprises 20 unilateral and bilateral hand tasks performed using standardised hand grip patterns intended to reflect normal function in activities of daily living [46]. Performance is graded by the examiner according to the quality of the grip and the time taken to perform each task. The scores range from 0 to 80, with normative values of 80 for the dominant hand and 77 to 80 for the non-dominant hand. Scores were 72.8 (range not reported) pre-treatment and 78.03 (range not reported) 6 months post-treatment [44]. A second study at the same centre reported scores of 71 (range 62 to 80) pre-treatment and 77 (range 66 to 80) 6 months post-treatment [45]. Neither publication reported whether the improvement was statistically significant.
Physical measures
Range of movement was the most frequent measure and was reported in all 91 studies. However, the methods of recording range of movement varied, with 17 different descriptors. Table 2 summarises the range of motion reporting of all studies. Techniques most commonly used in order of frequency included measurement of flexion contracture (n=24), joint extension deficit (n=18), Tubiana system which grades the DD contracture into one of four stages based on the combined angles of the MCP and PIP joints (n=16), active flexion and extension deficit (n=16) and the use of author defined categories such as 'improved' or graded according to degree of contracture defined by the author (n=14). Twelve other methods were used in 35 studies (Table 2). Follow-up times post treatment ranged from 2 weeks [27] up to 17 years [47].
Table 2. Range of motion reporting: all studies n=91 (NB. 29 studies reported more than 1 method)
Grip and Pinch strength
Measurements of grip strength or pinch grip were presented in 11 studies but only 3 reported pre- and post-intervention data [23,25,29] and 3 gave a descriptor of post-treatment outcomes, for example 'no significant change or deterioration' [20,48,66]. Follow-up times ranged from a median of 81 days [66] to a mean of 3.5 years [28].
Of 11 studies that reported sensibility testing, only one presented pre- and post-operative data [23]. Sensibility was tested using two-point discrimination (2PD) in 6 studies, Semmes Weinstein Monofilaments (SWM) by 1 group and assessment of light touch by another using the fingertip. No collagenase injection studies recorded sensibility. Three studies reported testing sensibility but data were not presented [16,86,87]. Follow-up times after treatment ranged from means of 10 months [23] to 4.4 years [105].
Figure 2 summarises the frequency of the various functional outcomes used before and after each type of intervention.
Figure 2. Frequency of outcome measures used and number of studies that measured before and after treatment.
Our review highlights the heterogeneity of outcome measures used for reporting the results of treatments for DD and the challenges faced when attempting to interpret data to determine best practice. Furthermore, many studies reported in insufficient detail how data were collected. Inconsistencies of outcome measures used and follow-up times have been highlighted previously [12].
The importance of utilising a set of commonly accepted outcome measures that are validated is paramount so that the natural history of the disease as well as treatment success can be monitored at both the patient and population level to enable meaningful comparisons between treatment modalities. Therefore, there is an urgent need for a common consensus regarding the reporting of outcomes data collected in high quality studies.
Patient reported outcome measures
PROMs, although subjective, are critical measures of treatment efficacy as patient perceived benefit is the ultimate goal of treatment. They should, therefore, supplement data derived from physical measures as they provide the context of the impact on function for the individual. PROMs including functional measures have gained prominence with the current emphasis on patient centred clinical practice. Yet, no publication of collagenase injections used PROMs as an outcome and only 15 publications reporting surgical outcomes used function PROMs. Only one RCT reported outcomes using function PROMs [24].
The DASH questionnaire is a 30-item self-rated region-specific disability and symptom scale outcome measure. It was the most commonly used function outcome measure but may lack the sensitivity to detect significant improvement following surgical or injection treatment for DD due to a 'flooring effect', that is relatively low pre-treatment scores resulting in a reduced potential for improvement [24]. It is difficult to be certain whether this represents a genuine problem as only 6 studies reported pre-treatment DASH scores, although all showed comparatively low values. The normal mean value for the DASH questionnaire reported by the American Academy of Orthopaedic Surgeons [110] was 10.10 (+/- 14.68 SD). All publications reporting pre- and post-operative data showed a reduction in post-operative scores, indicating an improvement in function compared with pre-operative levels, but this reached significance in only two studies [22,23]. A difference of 15 points is considered to be the minimal clinically important difference (MCID) indicating an improvement [111]. However, the exact figure is controversial and may vary according to the upper limb disorder being considered. No studies achieved a MCID equal to or more than 15 points and only two studies showed a MCID of 10 points [22,25], which may in part be attributed to the relatively low pre-treatment scores. Additionally, caution is advised when applying MCIDs due to difficulties with variation over time of in the patients' perception of their disability [112]. Thus, whilst the evidence for assessing the outcomes of interventions for DD using DASH indicates that it may be useful, further work is necessary to determine the level of change that is considered meaningful.
The Michigan Hand Outcome Questionnaire (MHQ) is a 37-item region-specific outcome measure that includes 6 sub-scales of activities of daily living, hand function, pain, cosmesis, patient satisfaction and overall function [31]. The MHQ has been shown to detect change in function following surgery for DD [23,25] and to correlate with changes in fixed flexion deformity [25]. The MHQ focuses on the hand as compared with the DASH, which assesses entire upper limb function. Furthermore, unlike DASH, the MHQ assesses the functional impact on each hand separately; this may be especially relevant to conditions such as DD that can affect both hands to varying extents. It also includes questions that may be of greater relevance for people with DD. For instance, aesthetics are a construct in the MHQ not included in the DASH and may be relevant for some patients with DD, for example when shaking hands [3] or when presenting the hand with the palm uppermost as when receiving coins.
Whilst the MHQ may appear to be more suitable than the DASH to assess DD outcomes it is lengthy, comprising 74 questions, and may not always be completed. Short versions of the DASH and MHQ have recently become available. The Quick-DASH was used by one study [66] but it is not clear if it is prone to a flooring effect when used for DD. The use of the short MHQ has not yet been reported in outcomes studies for DD. Pain, which is included in both the DASH and MHQ, is seldom reported by people with DD [113] and may reduce the sensitivity of both tools.
The PEM has been shown to be sensitive to change when used for patients with scaphoid fractures or carpal tunnel syndrome [114]. In a study of 100 patients with various conditions affecting the hand [115], including 15 who had DD, patients were able to complete it more rapidly than the DASH or MHQ. A sub-analysis of the results for the patients DD has not been published. Therefore, it is not possible to assess the sensitivity to change in the context of DD.
While there are a number of other hand function questionnaires, these have either been validated for use with specific conditions such as the ABILHAND for rheumatoid arthritis, chronic stroke and systemic sclerosis [116] or do not assess the area affected by DD, such the Patient Rated Wrist Evaluation (PWRE) [117]. Disease-specific hand function questionnaires are generally considered to be desirable as they focus on activities that specifically affect the study population, usually having been developed with patient participation. An example that has been shown to be sufficiently sensitive to change is the Boston questionnaire for carpal tunnel syndrome [118]. Recently the Unité Rhumatologique de Affections de la Main scale (URAM) questionnaire [15] and Southampton Dupuytren's Scoring System [119] have been developed as disease specific questionnaires, but have not yet been validated by other investigators.
An alternative approach is to ask individual patients to identify their most restricted activities and when applied to DD, significant improvement in median scores were reported [22].
Patient satisfaction
Methods used to report patient satisfaction varied, with no single measure used consistently. Studies reported overall satisfaction or satisfaction with surgery but did not explore the relationship with hand function. One study of collagenase injection [78] correlated satisfaction with treatment and improved range of motion at 30 days after the last injection.
Tests of function
Functional tests are used to provide objective 'measurable' assessment of function. However, critics question their ability to accurately reflect function due to the strict test conditions. Speed of task completion is used to identify change and does not reflect everyday conditions experienced by the patient. The Sollerman was the only functional test used to date in patients with DD. The 2 studies [44,45] using this measure were undertaken in the same centre in the UK, with both reporting change. However, lack of information on reliability, validity and sensitivity for patients with DD, together with lengthy completion time [120] and the need for cumbersome equipment, may limit widespread use.
Physical measures
Range of movement
Range of motion was the most commonly used outcome measure and was reported by every study. It is sensitive to change and benefits from a high inter-rater reliability for patients with DD [121]. However, the relationship between the degree of flexion contracture and loss of function in patients with DD is not necessarily linear [9,29,122], and the amount of change of motion required to translate into a significant functional improvement is unclear and may vary according to the patient and disease severity prior to treatment.
Although ROM was documented in all studies, the reporting was not standardised, making comparison between publications difficult. While studies may appear to be describing the same measure (joint extension deficit, fixed flexion deformity, flexion deformity, flexion deficit, extension contracture), the lack of a standardised measurement protocol means that this cannot be assumed. For example, many studies did not state how hyperextension was recorded, a common finding at the distal interphalangeal joint or as a compensatory movement at the metacarpophalangeal joint (MCPJ) especially for the little finger in patients with isolated proximal interphalangeal joint (PIPJ) contractures. Fixed deformities should be recorded separately and whether the apparent fixed flexion at the PIPJ can be overcome by flexing the MCPJ should be noted.
The grading system originally described by Tubiana was the joint third most frequently reported measure used for ROM [123]. Clinically it allows easy identification of improvement but not the location of change as it combines the measures of the MCP and PIP joints. Therefore, we suggest that if using the Tubiana grading, it should be supplemented with additional measures to detail the individual joints at which the improvement has been achieved. Similarly, composite ROM measures of finger joints, such as total active motion (TAM), do not permit identification of change at individual joints.
Measurements of pinch and grip strength are important aspects of hand function [124] and have been shown to have a strong correlation with disability [125]. However, only 3 of 10 studies that recorded grip or pinch grip strength presented data before and after treatment. Furthermore, assessment of grip and pinch were often not standardised. Grip strength is best measured using a protocol such as that recommended by the American Society of Hand Therapists. A reliable assessment of grip strength is important to capture clinical changes in interventional studies.
Sensibility testing was mainly used to monitor complications such as inadvertent nerve injury [16,87]. Most authors assumed that participants had normal sensibility before intervention, with only one recording pre-treatment values. Although testing using Semmes Weinstein Monofilaments has been shown to be a superior measure of sensibility assessment following nerve injury than static two point discrimination [126], they were used in only one study.
Limitations of the review
Excluding articles not published in the English language may have led to potential bias and heterogeneity of studies precluded pooling of data for meta-analysis. The inclusion of low quality studies presenting retrospective data may be viewed as a limitation but an exclusive approach would have resulted in an incomplete picture of current methods used.
Studies to date on the outcomes of treatments for patients with DD are heterogeneous and of relatively poor quality. It is critical to achieve a consensus regarding validated outcome measures to monitor disease progression and treatment success in order to enable comparisons between treatment modalities. Subtle deterioration of hand function with functional adaptation in patients with DD over time makes this challenging. Therefore, it is important to use measures that accurately assess global and local disability in a sensitive and specific manner in order to successfully evaluate any change in hand function as a result of intervention. Change in hand function is best assessed by a combination of physical measures and questionnaires [127]. DD can affect multiple digits of the same hand but can also occur bilaterally so comparison with the contralateral hand is not always possible. Inclusion of more than one hand or finger per patient and patient drop out resulting in varying numbers at follow-up represent possible sources of bias.
Based on our findings we recommended the use of a region specific questionnaire such as the MHQ and a validated disease specific PROM like the URAM. A useful addition would be designation of tasks important to each patient and indicating on a linear scale the degree of difficulty before and after treatment. Patient satisfaction should be assessed using a valid and reliable questionnaire such as the Picker questionnaire [128] or PEM. Physical measures of joint ROM, grip and sensibility should be included, with ROM measured before and after treatment using a standardised protocol. We recommend recording measurement of active flexion and extension of each joint and including whether an apparent fixed flexion deformity of the PIPJ can be overcome with passive flexion of the MCPJ. Grip strength should be measured using a validated instrument, such as the Jamar dynamometer according to a standardised protocol. Assessment of sensation using Semmes Weinstein Monofilaments should be used to monitor complications.
Hand function may also be compromised by recurrent disease. Scheduling of follow-up assessments may differ between surgery and other less invasive interventions but final follow-up time should be standardised to capture recurrence and understand how this affects function [129]. Following needle fasciotomy and collagenase injection initial improvement in range of motion and satisfaction may compare favourably with surgery in the short-term but recurrence may compromise function and satisfaction in the long-term.
A comprehensive and consistent approach will enable the development of a robust and reliable evidence base upon which to base best clinical practice for the treatment of patients with Dupuytren's Disease.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CB, ALP performed the literature search and together with JN analysed the data. All wrote the manuscript. All authors read and approved the final manuscript.
We would like to thank K. Bull Librarian, Kennedy Institute for Rheumatology, University of Oxford for her assistance with the literature search as well as James Chan, Liaquat Suleman-Verjee and David Izadi for their critical appraisal of the manuscript.
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Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Actor, producer, comedian, writer, and director Marlon Wayans, 41, is the youngest of the ten Wayans siblings. Youngest children notoriously vie for attention, and in a recent appearance on The Conan O'Brien show, Wayans, well, he became a UGer.
Wayans' interest in MMA came to light when the UFC Twitter account re-tweeted this.
marlon wayans @MarlonWayans
When questioned about it by O'Brien, Wayans doubled down.
Conan O'Brien: You tweeted something recently I have to ask you about. You tweeted about UFC fighter Ronda Rousey. And you said that you...what was it that you said? That you wanted to. You have sort of a fixation with her?
Marlon Wayans: Um
Conan O'Brien: You wanted to smell her training gloves and feet wraps? Did you tweet that?
Marlon Wayans: Ya, but here's why.
Conan: You either did or you didn't. You were sort of acting like 'we are we getting with this Conan' and then suddenly it went to 'Yaaaa'.
Marlon Wayans: Well here's the thing. I say that in a good way. Cause I know there's pheromones in those gloves and feet wraps. And I have a crush on her. I think she's dope.
Conan O'Brien: We have a picture of her actually wailing away on someone. And so...
Marlon Wayans: That's just sexy ain't it? Look how aggressive she is. There's something just about a woman that can you kick your behind. There's just something sexy about it. I want Laila Ali to just punch me in the face. I want her to just take me...cause she does this move..an armbar.
Conan O'Brien: You want to be beaten by a women is what you're saying?
Marlon Wayans: Well just some professionally, professionally though. So I want to wrestle around with her and I want her...I got a fantasy man I want to wrestle around with her. She makes people tap out. In like three minutes. She makes them tap out because grabs their arm and she breaks it back. I want her to grab my penis, and just grab it and pull it back...until I tap out. Tap tap tap tap tap tap.
Conan O'Brien: You won't have to tap out. She'll know when your done...it will be obvious
Recent Comments »
4/19/14 3:54 AM by theoutsiders
Yes, and it was an amazing movie. Apparently to the UG scary movie was the best he's done lol
4/19/14 3:44 AM by Rob Collins
what an idiot
4/18/14 11:40 PM by thorsmitersaw
He was In requiem for a dream.. right?
4/18/14 11:36 PM by zackthewop
No a teenage girl would be the one who actually has a Twitter.
4/18/14 11:29 PM by EEKS
The Wayans Bros. show was hilarious. Love me some pops.
4/18/14 10:59 PM by rkm456
Weird that some people know the Wayans Bros did stuff before 2000, right?
4/18/14 10:11 PM by Mma4life84
Don't be a menace on Conan O'brien while drinking your juice in the hood IMO
4/18/14 10:03 PM by time traveling 12er
If you don't know how talk shows work, the actor sits down with a writer before the show and they discuss what they want to talk about. So most likely Marlon requested that the tweet be brought up so he can do this bit.
4/18/14 9:51 PM by BooZe
Anybody older than 26 I'm sure they do...
4/18/14 9:49 PM by TheFaintingGOATClownedAwayMySN
I laughed


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Marine View Bed & Breakfast
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Travel Blogs from Seattle
On to Portland!
... The hotel is directly opposite Jack in the Box, so we walked over to peruse the menu: nothing I could eat :( the same went toe Taco Bell and every other place we saw on our walk to Safeway. Eventually we came to a bar called 'Alchemist Cafe' - a kind of alternative/rock bar with games room (pool tables, arcade games) about 4 blocks from us. The menu had vegan options - I couldn't believe it!!! So we tried out their food. I have to say it was excellent value for money and we ...
Fourth of July
... think of Seattle they think of coffee. There's surprisingly little in Seattle about the music, surely by now they would have put up a statue of Kurt Cobain somewhere, but there's plenty about the coffee. We went to Pike Place market, it's a fascinating mix of bric a brac shops, florists, grocers, butchers, fish mongers, farmers selling everything from bees wax to wine. There's tie dye t-shirts, flags, all sorts really. It's fairly Bohemian ...
First day in Seattle!
... another cab. On my walk home, a random guy asked me if I knew where he could buy any weed at that hour. I don't know why he asked me because there were plenty of other people walking around.. So I hope I don't look like a pothead. (It was also really weird walking through the city and smelling weed on public streets because it's legal here).
I got home safely and without further event. My roommates were surprisingly still up, so we talked for a bit and ...
Heading to the Emerald city
... over where you can sit, for whatever reason they do this I can't understand. I proceeded to my aisle seat in a car full of people and loudly screaming children. Maybe that $20 upgrade to first could have been worth it. Also, this is not the scenic and glorious Amtrak Cascades train they advertise on the website for this route. No where to be found is the second floor with a ceiling of windows. The ride got better when the lady in the window seat next to me moved to an empty row. I ...
Lou's Retirement Party
... my home at 1225 25th Street. More memories crept up walking past the junior high. Out in the ball field there were kids practicing lacrosse where we played football. I could see Mr. Latham's room where I hid under my desk during the 1965 Big Earthquake. I walked part of the perimeter grounds where I had to pick up all the garbage on the campus with one of my buddies. We had gathered all the toilet paper from the ...


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50+ Solitaire Card Games
Kevin Tydlacka
- August 4, 2014
( 688)
The only card game you'll ever need! Play over 50 variations of Solitaire with clean, HD graphics, custom colors, hints, undo and more--all completely FREE! Try it now and see if you can master them all.
-Tap or drag cards
-Game Center
-Over 50 solitaire games
-Play in both portrait and landscape mode
-Crisp, clean graphics and easy to use controls
-Smooth animations
-Auto Play
-Custom colors
**Default Solitaire game is Klondike
Complete list of game types: Acme, Alhambra, Alternations, Auld Lang Sync, Aunt Mary, Baker's Game, Batsford, Beleaguered Castle, Blind Alleys, Blockade, Brigade, Busy Aces, Canfield, Capricieuse, Carlton, Carpet, Castles in Spain, Congress, Corona, Courtyard, Diplomat, Double Klondike, Double Rail, East Haven, Eight Off, Fan, Flower Garden, Fortress, Fortunes Favor, Forty and Eight, Forty-Nine, Forty Thieves, Freecell, Gargantua, Giant, King Albert, Kingdom, Klondike, Klondike - by threes, Lady Palk, Legion, Limited, Lucas, Maria, Martha, Midshipman, Milligan Harp, Napoleon's Exile, Number Ten, Octagon, Raglan, Red and Black, Royal Aids, Russian Solitaire, Scotch Patience, Single Rail, Somerset, Spider, Spider - One Suit, Spider - Two Suits, Squadron, Steps, Stonewall, Streets, Streets and Alleys, Tam O'Shanter, Thirty-Six, Tri-Peaks, Triple Line, Waning Moon, Westcliff, Whitehead, and Yukon
Unstable It doesn't save the settings dispite the save button. At times it stops working and when pressing new most of the time it resets to klondike again. And pressing info will result in an exit in 50% of the cases. There are better multi card games out there
Doesn't always work Crashes alot! sometimes you can't even move any cards when you start a new game. Sometimes the screen goes black for no apparent reason
Eh Banners get in the way of game play. The banners at the bottom of screen block touching cards on lower stack. I would not recommend this app to anyone.
Good one I always played these games on my laptop. But when I install this App on mobile device, I never start my laptop for game playing. Thanks...!
Worked when I installed it now won't work I think the ads are screwing it up on my phone. By the way to many ads.
My best companion during my travels & when i am alone or mood out.
What's New
-Bug fixes


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Doctor-nurse line is blurring
As president of the Oklahoma Osteopathic Association, I am alarmed by the increase in the number of colleges and universities offering the doctor of nursing practice (D.N.P.) degree. The D.N.P. program allows nurses who hold at least a master's degree to earn a clinical doctorate and treat patients in place of a physician. According to the American Association of Colleges of Nursing, there are more than 60 D.N.P. programs and more opening every year. In Texas, there are already four D.N.P. programs. Kansas has two and Missouri has one.
As additional programs open, the public needs to understand how expanding the scope of practice for D.N.P.s without appropriate expansion of their education, training and regulation may do more harm than good for patients. The program, which is typically two years, is not equivalent to the training of an osteopathic physician (D.O.) or an M.D., who are the only two fully licensed physicians in the United States. Both groups attend four-year medical schools followed by three to six years of internship and residency training in their chosen specialty area of medicine. As a physician, I find it hard to imagine how only two years of schooling and a condensed clinical training program can prepare D.N.P.s for the many difficult scenarios they may face while treating a patient. A comprehensive medical residency program prepares physicians by exposing them to patients presenting various symptoms of illnesses and conditions, allowing them practice in diagnosis and treatment. D.N.P. training does not provide adequate diagnostic experience to prepare these nurses for complex cases. I will not deny the important role that nurses play in the health care system. However, steps must be taken to increase access to health care without compromising quality of care and safety for patients.
Continue reading this story on the...


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I'm making an iPhone App which involves balloons (UIImageViews) being spawned from the bottom of the screen and moving up to the top of the screen.
The aim is to have the UIImageViews set up so that a tap gesture on a balloon causes the balloons to be removed from the screen.
I have set up the GestureRecognizer and taps are being recognized.
The problem I am having is that the animation method I am using does not provide information about where the balloon is being drawn at a specific point in time, and treats it as already having reached the final point mentioned.
This causes the problem of the taps being recognized only at the top of the screen(which is the balloon's final destination).
I have pasted my code for animation here:
UIViewAnimationOptions options = UIViewAnimationOptionBeginFromCurrentState|UIViewAnimationOptionAllowUserInteraction;
[UIView animateWithDuration:2.0 delay:0.0 options:options animations:^{
balloonImageView.center = p;
} completion:^(BOOL finished) {
if (finished) {
balloonImageView.hidden= TRUE;
I keep track of where an image is by giving a unique tag to a UIImageView and checking if gesture.view.tag = anyBalloonObject.tag and if it does I destroy the balloon.
My basic question is, is there another animation tool I can use? I understand that I can set a balloon's finish point to slightly higher than where it is on screen until it reaches the top but that seems like it is very taxing on memory. Do you have any recommendations? I looked through the Core Animation reference, and didn't find any methods that suited my needs.
In addition will the Multi-threading aspects of UIViewAnimation affect the accuracy of the tap system?
Thank You,


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Tao CafeFebruary 7, 2012Asian • Edmond, United States
Best value for fresh made Asian food! #milktea
Community! Brotherhood! We are one of the oldest fraternities in America. founded in bologna Italy in the 14th Century. we maintain diligence and commitme…
Chill, Fun, and pool! 21st birthdays never forget us!
We have had our fare share of birthdays at Chilli's
We usually find ourselves here on Monday nights!
This is one of our favorite places to hangout!


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Get to the pool
Gowdy's Bar on Main Street--amazing flat iron steak dinner on Saturday nights!!
Foursquare © 2015 Lovingly made in NYC & SF
Make sure your information is up to date. Plus use our free tools to find new customers.
Download Foursquare for your smart phone and start exploring the world around you!


text: More from SI Report: Dodgers release pitcher Freddy Garcia Report: Dodgers release pitcher Freddy Garcia Marshawn Lynch sports gold cleats for Super Bowl Marshawn Lynch sports gold cleats for Super Bowl Louisville vs. FIU: Game time, live stream, TV coverage Louisville vs. FIU: Game time, live stream, TV coverage Pittsburgh-area high school football player dies after... Pittsburgh-area high school football player dies after... Close Tweet0 Share0 Comment0 Share0 Share0 Stumble It0 Print0 More SI Wire Miami Dolphins Win No. 8 Pick With Coin Toss by Will Yoder Email Posted: Fri Feb. 24, 2012 The Miami Dolphins have won a coin flip against the Carolina Panthers to earn the eighth overall pick in the 2012 NFL Draft, according to the Dolphins' official website."I think it makes a big difference," Dolphins general manager Jeff Ireland said. "I've never been into a draft where I didn't feel like if you're at the 10th pick there are nine players and if you're the 22nd pick there's usually 20 players so you're usually right behind it. So the higher up the board I can get, as long as it's with the flip of a coin, I'll take it."The Panthers and the Dolphins both finished the 2011 season with a 6-10 record, and were also deadlocked in all other traditional tiebreakers. Last season Carolina owned the No. 1 overall pick and selected the eventual NFL Rookie of the Year, Cam Newton. Miami had the No. 15 pick last year.Instead of a traditional United States quarter, a custom coin was flipped. On one side was the Miami Dolphins' logo, on the other was the Carolina Panthers' logo. Promoted Stories Comments


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CLEVELAND c Diversified industrial manufacturer Eaton Corporation today announced that Lennart Jonsson has been named vice president, technology, and chief technology officer for the Electrical Group, reporting to Craig Black, vice president, Quality, Technology, and Integration. In his new role, Jonsson will be... Read More
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SOUTHFIELD, Mich. (June 18, 2007) - Tinnerman, a world leader in offering automotive and industrial equipment manufacturers connection engineering solutions that simplify and revolutionize the way products are assembled, has appointed Todd L. Hemingway to vice president of advanced engineering. In this role... Read More
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You may have heard the buzz about Paris High Noon, the story of William "Catfish" Hancock, an old cowboy who takes the fight to the Nazis on the streets of WWII France. Author Trent Tano will air an excerpt from his novel this Sunday, Oct. 6, on San Francisco's Radio Valencia, 4:00 Pacific. »
"Erin Wilcox is a truly gifted literary copyeditor. Her reading of the text is both meticulous and informed, and her insights are luminous."


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Try Out Some Of This Practical Home Security Advice to Avoid Fire Hazard
It is difficult to overstate the critical nature of keeping your home and personal belongings safe. Therefore, understanding the subject of home security and the options available is worth investing a fair bit of time. Keep reading to gain a thorough understanding of what your specific needs really are, and how you can meet them.
Did you know that many cable companies offer home security systems now? This is a great way to get a quality system installed and monitored in your home by someone you can trust. They usually offer very competitive rates with other home security companies as well. You may even get a discount if you have cable service with the same company.
Safety is most important for your family and it is worth investing for. If you're budget is very tight and you can't afford a home security system, it's better to take a cheapest consumer loan (billigste forbrukslån) available in your area. There are many best loans without collateral (beste lån uten sikkerhet) offered by different banks. Just choose the best one suitable for your needs and capability of paying it back. There are different cheap credit card (billig kredittkort) offer you can apply for emergency purposes.
Do not tell anyone that you are going on vacation out of your friend circle. Although your first instinct is to share the news about an upcoming trip that excites you, the info may well fall into the hands of people who'd be interested in burglarizing your home while you're away.
Fire safety (brannsikkerhet) tips if you are a smoker, put out your cigarette in a cup of water to prevent a fire hazard. This should be done before you put it in the trash, as you run the risk of the bud not burning out when you rub it in your ashtray. Smoke outside to reduce all risk of a fire occurring in your home. More fire safety tips and advice available at Firesafe AS.
While home security systems are effective in most cases, many robberies are committed during daylight hours when the home is not vacant. In this case, the security system may not be activated so no warning would be sounded. Most burglars enter the home at some other point than the front door. But still make sure you installed safety door (branndør) lock to your front and back doors.
There is no denying the high value homeowners necessarily place on home security. The truth, though, is that not all of them understand how to achieve their own objectives. The information provided above should serve as a handy, ongoing reference as you navigate the confusing landscape of home security planning.


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Dogs In Space - A Shout Out To Good Men!
in Art
Men and space? Recent studies show dogs in space are prime for human advancement. So are the wonderful men in our lives. If men think like waffles and women like sphaghetti, this hilarious 15 minute conversation will make you smile and be something to take with you throughout the day.
Dogs were the preferred animal during 1950s and 1960s USSR orbital space flights for the experiments because scientists felt dogs were well suited to endure long periods of inactivity. As part of their training, they were confined in small boxes for 15–20 days at a time. Stray dogs, rather than animals accustomed to living in a house, were chosen because the scientists felt they would be able to tolerate the rigours and extreme stresses of space flight better than other dogs. Female dogs were used because of their temperament and because the suit the dogs wore in order to collect urine and feces was equipped with a special device, designed to work only with females.[1][2]
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|Reviews for Shades of Blue Cerulean
| Grosspointeblankfan chapter 5 . 6/28
Ok, Rose and Doctor, happy Tardis, sex, telepathy and true-to-character story! I love it!
| Summer Leah chapter 5 . 6/16
Aww... Great story. Loved it.
| Hlpur chapter 5 . 6/1
| Depp-Knight2000 chapter 5 . 5/8
Omg that story was just too beautiful! :') 3 I loved it! :D 3
| Terra Elizabeth chapter 5 . 5/3
Loved the story can't wait to read the rest!
| alicewiggles chapter 5 . 3/17
oh ! that's beautiful
| Von chapter 6 . 1/19
Words can't express how much I enjoyed this. I love the characters, the development AND how you seem to be bucking canon rather than tailoring your story to fit. Fantastic. I'd write much more but I can't stand another second of not reading the next story!
| jocillyria chapter 6 . 12/2/2014
This has just knocked my socks off. I'm actually having trouble remembering that this isn't following an episode arc! I look forward to reading the rest of the series.
| Selias chapter 3 . 10/27/2014
That happened WAAAY too quickly.
| Crystalzap chapter 6 . 7/23/2014
Loved this though I can't figure out what 'deception' he is talking about sense he seemed to let her go and buried the memories as he said... well luckily for me there is a sequel :D Allons-y XD
| KarmaGetsMeGoing chapter 6 . 7/22/2014
Love love love this story! I haven't watched the DW movie yet so I don't know the Eighth Doctor but from how you wrote him, he seems to be a really nice bloke. I read this story in one sitting and you had me crying like a baby. Lol. I love your writing style. Going to read the next parts )
| callmebobbie chapter 6 . 6/29/2014
This is seriously the BEST Eight/Rose story I've read. I've read it, like, three times this month.
So awesome.
Off to read 'Blue Navy' now. For the third time. I'm not even sorry.
| Grac3 chapter 6 . 6/5/2014
This was an amazing story! No chips in the parallel universe? How did she cope? I absolutely love the way you've portrayed their relationship - and my heart broke when I realised that she was leaving him just before the Time War broke out. Just... ow. Really looking forward to reading the rest of this series.
| Ethell chapter 6 . 5/17/2014
So I was reading this story for the tenth time or so when I realized I've never reviewed it... So better late than never: I absolutely love it. Your characterization is spot on, the flow of the story is smooth and doesn't feel rushed, the dialogue is perfect. I love everything about it!
| TheCeruleanBlues chapter 1 . 4/18/2014
I think I've read this series at least 3 times through, and it never disappoints. This is one of the most incredibly well written, well thought out, detailed, descriptive, utterly GORGEOUS pieces of fanfiction I have ever read. Each part is better than the last. 3 Thank you, thank you, thank you for sharing it!


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Helpful (1)
"Less oversight would be better. Very secure and sometimes happy. "
- Work/Life Balance
- Culture & Values
- Career Opportunities
- Comp & Benefits
- Senior Management
I have been working at Bristol-Myers Squibb full-time (More than 3 years)
Top of our industry, lots of collaboration and facilities. 401k match, bonus and PTO are excellent.
It seems there are a lot of people and contractors here whose job it is to 'make scientists more efficient' This is no fun, and people make money selling us plasticware tracking software, databases and network groups.
Advice to Management
Give us a break and let us into the lab more. Also, stock options for lab people, not just lawyers and business managers. It just goes better for everyone if we have skin in the game. Internal promotions would be nice too.
Other Employee Reviews for Bristol-Myers Squibb
"Oncology "
RecommendsNeutral OutlookNo opinion of CEO
- Work/Life Balance
- Culture & Values
- Career Opportunities
- Comp & Benefits
- Senior Management
I have been working at Bristol-Myers Squibb full-time (More than 8 years)
benefits - great health care benefits, car, and bonus. Dependent on location /state/city dictates how much travel you will do.. Can be fun in accounts
Heavily based on Metrics.. Very slow decision making by senior management. Very slow. At times seems it ADVERSARIAL attitude between management and field.
Advice to Management
Ask reps for advice not only the MBA'S that never been out in the field
- RecommendsPositive OutlookApproves of CEO
I have been working at Bristol-Myers Squibb full-time (Less than a year)
This is my first job after graduate school. BMS is friendly for entry level scientist to start career. working hours can be flexible. good for women.
Recent lay off have affected this company, a little down sizing has happened. Location is not very attractive. benefits are not as good as before
Advice to Management
increase training opportunity for young scientist, need to increase travel to scientific meetings and workshops